Corporate Director Risk Adjustment Finance

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Job Summary

The Corporate Director, Risk Adjustment Finance is accountable for end-to-end risk adjustment financial performance, analytics, and strategy across Medicaid, Medicare, and Exchange lines of business. This role leads a team that delivers executive-level forecasting, modeling, performance reporting, and decision support in partnership with Actuarial, Finance, Network, Product, and Sourcing. The Sr Director also serves as a senior representative for risk adjustment in regulatory, audit, and advocacy discussions with federal and state stakeholders.

Essential Functions:

• Lead enterprise alignment for risk adjustment strategy across internal and external stakeholders (e.g., Network, Product, Actuarial, Sourcing, and regulators) to influence decisions for all risk-adjusted lines of business and drive implementation of prioritized initiatives.

• Lead market and regulatory intelligence efforts (e.g., competitive landscape changes, new entrants/withdrawals, and policy updates) to quantify financial risk/opportunity, recommend strategic actions, and drive execution plans.

• Establish and maintain executive-ready reporting and operational transparency for risk adjustment program execution and the submission pipeline (e.g., throughput, yield, timeliness, accept/reject performance, reconciliation status, defect trends, and outcomes), including defined accountability and escalation paths.

• Define, govern, and continuously improve enterprise risk adjustment KPIs (e.g., encounter acceptance/reject rates, resubmission cycle time, claims-to-encounter reconciliation, diagnosis capture/completeness, chart/EMR yield, coding accuracy/QA, provider engagement effectiveness, and audit outcomes).

• Oversee risk score calculation, projection, and trend analytics and lead financial modeling for all risk-adjusted lines of business; provide direct support for actuarial forecasts and bid/pricing activities, including review and approval of risk adjustment assumptions used in forecasting and pricing.

• Own the strategy and analytics for Risk Adjustment Data Validation (RADV) audits across Medicare and Exchange, including partnership with Risk Adjustment Operations on chase lists, quantification of potential financial impact, regulatory-facing data communications, and escalation of progress, issues, and risk to senior leadership.

• Lead regulatory intelligence for risk adjustment by monitoring and analyzing federal and state policy changes; drive alignment with Legal and Compliance on requirements and risk; and represent organizational positions through engagement with regulators and industry organizations (e.g., AHIP).

• Measure and report ROI and performance of prospective and retrospective interventions, vendor partnerships, and provider engagement campaigns; translate findings into targeting refinements, operational changes, and investment recommendations.

• Lead validation and reconciliation of risk adjustment submission data to ensure accuracy, completeness, and readiness for audit and settlement (e.g., claims-to-encounters, eligibility/attribution, and submission acceptance/rejection remediation).

• Establish, improve, and document risk adjustment financial and analytic processes, controls, policies, and procedures (including peer review standards) to strengthen governance, repeatability, and auditability.

• Lead, coach, and develop Data/Actuarial managers and analysts; build leadership and technical bench strength; and ensure analytic and reporting solutions are built and maintained for quality, efficiency, and scalability.

• Communicate risk adjustment objectives, performance, and issues to associates and leaders across levels; facilitate governance forums; and drive resolution of cross-functional dependencies to enable delivery of program outcomes.

Education/Experience:

• Bachelor’s Degree.
• 10 or more years experience.

Other Skills:

• Actuarial or analytical background required.
• Knowledge of Medicaid, Medicare, and/or Exchange Risk Adjustment mechanism and regulations required.
• Knowledge of CDPS Rx, CMS-HCC, and/or HHS-HCC required familiarity with actuarial pricing/bid/forecast processes including rate review and desk review required.
• Advanced predictive modeling knowledge preferred.
• Advanced SAS, SQL, or Python knowledge required.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.